Provider Demographics
NPI:1154632073
Name:ANDERSON, VIVIENE
Entity Type:Individual
Prefix:
First Name:VIVIENE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 DOGWOOD RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4002
Mailing Address - Country:US
Mailing Address - Phone:516-561-2109
Mailing Address - Fax:
Practice Address - Street 1:192 DOGWOOD RD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-4002
Practice Address - Country:US
Practice Address - Phone:516-561-2109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007684-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist